Social Anxiety Treatment

How to Overcome Social Anxiety?

Living with Social Anxiety Disorder, or SAD, can be one of the major challenges in a person’s life. This is true whether an individual is officially diagnosed, or simply experiences social anxiety symptoms on a regular basis which significantly impact her quality of life.

The first step to overcome social anxiety is to seek help, and most people never do so. In fact, more than 80% of affected people never receive treatment for social anxiety during their lives (Grant et al., 2005).

A study performed by Coles, Turk, Jindra and Heimberg (2004) found that only 15% of socially anxious people who initially contacted an anxiety clinic proceeded to receive therapy.

About 80% of people with social anxiety disorder never receive professional help, despite effective treatments being available. Paradoxically, this is often due to the fear of being judged or negatively evaluated by the therapist.
About 80% of people with social anxiety never receive professional help.

Among the reasons why people refrain from seeking or accepting professional help seem to be the potential economic burden, a lack of professionals familiar with the dynamics of social anxiety disorder or having to travel long distances to see them, and paradoxically the fear of being judged and negatively evaluated by the therapist (Mechanic, 2007; Olfson et al., 2000).

Those who do seek help usually find one response: “Cognitive behavioral therapy (CBT) is the only effective treatment for social anxiety disorder”.

But is that really the case or are there alternative approaches that have been scientifically studied, proven effective, and can potentially cure social anxiety?

The Silver Bullet for Social Anxiety: Does it Exist?

Social anxiety disorder accounts for the third most common mental health condition in the world today. However, finding valid, trustworthy and upright information concerning the disorder can be quite challenging.

Many affected people turn online in order to find answers to their questions. When it comes to overcoming social anxiety, many self-proclaimed gurus declare they have found the secret formula:

  • “Overcome social anxiety completely
  • “Beat social anxiety within days
  • “Crush your insecurity and turn into a social beast
  • “Cure your social anxiety in one session

Promises like these are tempting, especially for people who are suffering and are looking for a way to get better fast. Ethically, claims of this type should be questioned. Even if there were an easy and magic solution, it would still be problematic promising a suffering individual that you will provide it with certainty.

Social anxiety was officially recognized as a disorder in 1980 by the American Psychiatric Association (APA). Ever since, researchers all over the world have been trying to better understand the phenomenon and come up with effective treatments.

For many years, cognitive behavioral therapy (CBT) was considered the go-to treatment for social anxiety and for many mental health professionals it still is.

But CBT is not the only valid treatment option. The last decade was an exciting time in the area of social anxiety research. The recent mindfulness wave has brought along changes in existing treatment plans and has created completely new approaches.

None of the scientifically studied therapies can be regarded a silver bullet – they still require effort and time, and they do not turn a person’s personality and life upside down.

However, many studies have shown that they often lead to significant reductions in social anxiety symptoms as well as subjective suffering and that they can lead to remission of the disorder in many cases.

So, what are the official treatments for social anxiety disorder? Let’s have a closer look at them.

Psychotherapy for Social Anxiety Disorder – The State of The Science

There has been extensive research on the effectiveness of different treatments for social anxiety disorder. In recent years, the field has come up with important insights which have led to significant alterations in existing therapies as well as created completely new approaches.

While treatment plans for social anxiety that were developed in the 90’s encouraged to challenge and actively change intrusive thoughts, newer approaches advocate acceptance of these as well as of uncomfortable feelings.

Although much remains to be discovered, there have been some exciting findings which make psychotherapy for social anxiety increasingly effective.

Given that it is not easy to find pertinent and holistic information concerning treatment for social anxiety, we have put together an eBook which summarizes the 17 distinct approaches that have been scientifically studied.

We have decided to make it available to the public for free, since we want to encourage affected people to be well informed about different ways to overcome their social anxiety.

In case you want to learn more about our eBook, its content, and whether or not it can help you get a quick and thorough picture of available social anxiety treatment options, feel free to head over to the following section.

When talking about treatment for social anxiety, cognitive behavior therapy has to be included in the conversation.

As mentioned before, it is widely considered the standard treatment for social anxiety disorder and is oftentimes able to cure or at least significantly reduce it.

CBT is based on the premise that dysfunctional beliefs and behavior patterns cause and maintain social anxiety symptoms. Let’s learn the basics.

Cognitive Behavioral Therapy for Social Anxiety Disorder

Cognitive behavior therapy for social anxiety is based on the cognitive model of SAD. Several models have been proposed. However, most of them are simply slight variations of the most commonly accepted model by Clark and Wells (1995).

The cognitive model of social anxiety disorder by Clark and Wells emphasizes past negative experiences which lead to an interplay between negative thoughts, self-consciousness, anxiety symptoms and safety behavior. Cognitive behavioral therapy for social anxiety aims to breaks this vicious cycle.
Cognitive behavioral therapy aims to alter negative beliefs and assumptions, and targets maladaptive attentional processes and behavior patterns.

The cognitive model of social anxiety disorder emphasizes the importance of past negative social experiences for the development and maintenance of the condition.

A person might have been laughed at for making a mistake when reading out loud in class during adolescence. Whenever a similar social situation arises, memories and related negative beliefs as well as assumptions about herself and others are triggered.

Possible beliefs in this particular case could be:

  • “I will make a fool of myself when reading the outline of the meeting to my colleagues.”
  • They will notice how nervous I am and make fun of me.”
  • No one will respect me anymore and my boss will think I am incompetent.”

These thoughts are believed to fuel self-consciousness, anxiety symptoms and safety behavior. In turn, these components are believed to feed of each other, increasing the person’s social anxiety even further.

In the example mentioned in the graphic, the person may excessively practice reading the outline beforehand in an attempt to control her anxiety symptoms, which likely produces a paradoxical effect, further increasing her arousal.

She might imagine the worst case scenarios before the event and see herself as insecure while presenting the outline, which yet again worsens her anxiety symptoms. These, in turn, will increase her self-consciousness even further, trapping her in a vicious cycle of social anxiety.

Cognitive behavioral therapy for social anxiety disorder reduces anxiety symptoms by changing negative thoughts, training the person's ability to deliberately direct attention away from fear-provoking stimuli, and by seeking exposure to the feared social situations.

Cognitive behavior therapy for social anxiety attempts to alter negative thoughts related to the feared situations, train the person’s ability to deliberately direct her attention away from her bodily sensations and how others may see her, as well as encourage exposure to the feared situations.

This combination of interventions usually leads to a decrease in social anxiety symptoms as well as improves the person’s ability to face and deal with the feared situations. A large body of evidence supports the effectiveness of CBT treatment for social anxiety disorder.

Psychodynamic Psychotherapy for Social Anxiety Disorder

Another well-studied, but often underrated approach is psychodynamic treatment for social anxiety. Psychodynamic therapies are interested in the underlying, often unconscious emotional conflicts that may cause social anxiety.

These often unconscious drives have been described as a “conflict between craving praise and dreading not receiving it; wishing for adulation amidst the worry that it is undeserved(Hoffman, 2018, p. 7).

An insecure attachment style has been found to possibly predispose an individual to develop social anxiety disorder.  Psychodynamic treatment for social anxiety tries to identify patterns in a person's way to relate to others. These are usually formed in early childhood and depend on a person's attachment style.

According to various psychodynamic research interviews (McEvoy, O’Connor, & McCarthy, 2016), one of the main developmental struggles for people suffering from SAD seems to be reaching an authentic self – an own identity which has its own opinions, aware of its needs and wishes and is able to give voice to them in interaction with others.

Most people with social anxiety wish nothing more than being accepted, noticed and admired by others. When this desire is very intense and the person is convinced to not be worthy of love and approval, an inner conflict may arise, which can lead to intense emotional reactions in situations of possible social evaluation.

However, this conflict and the underlying wishes and convictions may be unconscious. Psychodynamic psychotherapy for social anxiety disorder aims to gain clarity over these aspects and provide new ways of positioning the self in relation to others.

Psychodynamic psychotherapy for social anxiety disorder argues that most people with social anxiety crave acceptance and admiration, while believing at the same time that they don't deserve it. This conflict leads to social anxiety symptoms.

Among the main differences in comparison to other approaches is the focus on early childhood experiences, especially the relationship to parents and early childhood caregivers of the individual, and how these affect the patient’s experiences in the present (Leichsenring et al., 2013).

Mindfulness & Meditation for Social Anxiety Disorder

The mindfulness wave of the last decade has led to significant adjustments in the treatment of social anxiety as well as created completely new approaches. One of its main ideas relates to the tendency to fight uncomfortable thoughts, feelings and sensations.

Socially anxious people usually try to combat their anxiety or physical symptoms, which tends to intensify them. Mindfulness teaches to observe and notice what is happening without the intention to alter the experience in any way.

Mindfulness has been described as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally”, by Jon-Kabat-Zinn (1994) from the University of Massachusetts Medical School.

Mindfulness has been described as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally”, by Jon-Kabat-Zinn (1994) from the University of Massachusetts Medical School.

It can be seen as a practice which has the potential to decrease our natural tendency to fight any unpleasant experiences. For this reason, it represents an intervention with great potential for socially anxious people.

Instead of challenging uncomfortable feelings and counterproductive thoughts, mindfulness-based approaches for social anxiety teach psychological acceptance of these phenomena.

Like this, it bypasses the ironic thoughts process – a psychological phenomenon which paradoxically intensifies a thought or sensation when the person actively tries to suppress it.

Regular meditation and mindfulness practice have been shown to increase activity in the prefrontal cortex and lower the  amygdala response in stress situations.

But this is not the only reason why mindfulness meditation can be considered an effective treatment for social anxiety.

Regular meditation practice has been shown to affect brain activity, as the prefrontal cortex becomes thicker and gains more influence over the amygdala, also referred to as the fear center of the brain.

In stressful situations, the brain is then more likely to remain calm and not overreact when there is no real objective threat.

In the case of social anxiety disorder, the threat is often imagined or drastically amplified by the affected person. Therefore, training the brain through meditation in order to maintain control in stressful situations is a great practice for socially anxious individuals.

To learn more about mindfulness as well as other types of meditation, and how you can use them as an antidote for social anxiety, feel free to visit our guided meditations section.

Compassion-Based Treatment for Social Anxiety Disorder

Another new treatment for social anxiety that has been emerging over the last two decades is based on compassion. Compassion refers to a “sympathetic consciousness of others’ distress together with a desire to alleviate it(Merriam-Webster, 2020).

Compassion-focused therapy is based on the idea that humans evolved having three different basic motivational-emotional systems (Gilbert, 2014).

While the threat and competition systems tend to activate and arouse us, the affiliative system has soothing qualities and puts us in a prosocial state.

When this latter system is activated, our brain works and organizes its activity in a way which promotes mental health and significantly lowers anxiety.

Compassion-focused therapy aims to train people’s ability to cultivate affiliative emotions related to others and towards themselves.

Reacting with self-kindness and self-compassion when faced with personal flaws or failures has been shown to have an anxiety-buffering effect (Werner et al., 2012).

However, socially anxious people tend to miss out on this mental health benefit due to their low levels of self-compassion and their marked habit to criticize themselves. In fact, people with social anxiety disorder represent a group with particularly high levels of self-criticism (Cox, Fleet, & Stein, 2004).

Another therapy for social anxiety which is based on the way we relate to ourselves is mindful self-compassion (Neff, 2003). As the name suggests, it focuses on becoming aware of our own suffering and reacting with compassion and kindness when we have to endure difficult moments.

Socially anxious people have a strong tendency to be harsh on themselves when it comes to their flaws, particularly their own social anxiety. Mindful self-compassion advocates the idea that criticizing ourselves when we are down only amplifies the problem and our suffering.

Instead of putting ourselves down, it encourages people to react with compassion for themselves, as they would with a friend who is going through a difficult moment.

Cultivating self-compassion in the face of one's own shortcomings has been shown to lower anxiety in people in public speaking scenarios.

Harwood and Kocovski (2017) examined what happened when people high in social anxiety measures engaged in a self-compassion inducing exercise before a speech task. Results showed clear benefits for these individuals and confirmed once again the anxiety-buffering effect of self-compassion.

Metacognitive Therapy for Social Anxiety Disorder

While the traditional cognitive model highlights the importance of maladaptive social beliefs about the self and others, the metacognitive model emphasizes that certain beliefs about thinking itself play a crucial role in SAD.

That is, instead of focusing on the ideas an individual has about herself or others in a given social situation, it addresses her beliefs and habits related to her cognitions. If this still seems confusing, stick with us for another moment.

Socially-anxious people tend to assume that certain thoughts are dangerous and that controlling them will therefore be beneficial.

Their attempts to do so, however, often fail and thus confirm their beliefs about the dangerousness of certain thoughts, further strengthening the monitoring of their mental processes in social situations. This phenomenon is referred to as cognitive-attentional syndrome (Wells, 2009).

Metacognitive therapy proposes that our thinking styles can cause psychological suffering, not the specific content of our thoughts themselves.

Our metacognitions lead to certain thinking styles (Wells, 2009). In the case of social anxiety disorder, a person may believe it is helpful to worry about what could go wrong in an upcoming social event in order to be prepared.

In the same way, she might think that ruminating about a past event can help her avoid certain behavior or physical symptoms in the future. These beliefs about thinking tend to increase the anxiety instead of reducing it.

People with social anxiety are usually highly alert when with others and tend to focus on any signals of social threat or disapproval.

Many affected people believe that being hypervigilant to such signals can help them detect potential danger and avoid it. What this really does in most cases is putting the individual in a state of constant alert which raises anxiety levels.

Metacognitive therapy for social anxiety targets this phenomenon and its underlying beliefs about mental processes (Nordahl & Wells, 2017). Our blog post on the topic illustrates how metacognitive therapy approaches treatment of social anxiety disorder.

Online Treatment for Social Anxiety Disorder

Already in the 1990’s psychological interventions began to be developed and carried out online. Due to the nature of social anxiety disorder, this way of treatment delivery has been well-received by many affected people.

The fear of exposing oneself to another person is among the main reasons why people with social anxiety refrain from seeking professional help (Olfson et al., 2000). Other reasons include the potential economic burden, a lack of professionals specializing in SAD or having to travel long distances to see an expert (Mechanic, 2007; Olfson et al., 2000).

Online therapy for social anxiety disorder lower the threshold of seeking treatment. It provides a great opportunity for those individuals who otherwise would never seek professional help.

As mentioned earlier, about 80% of people with SAD never seek professional help. The possibility of receiving treatment for social anxiety through the internet has the potential to improve these numbers significantly, since it can lower the threshold for entering a psychotherapeutic process.

Therefore, online therapy for social anxiety represents a major breakthrough in the field, especially in the light of opening doors to professional help for many people who would otherwise never receive treatment.

Advantages & Disadvantages of Online Therapy for Social Anxiety Disorder

Increases the number of people who receive professional helpPotentially maintains social avoidance **
Enables better retention of the presented information and allows for quick & proactive help by a professional.*Lacks susceptibility to individual clues important in psychotherapy. There is still missing knowledge about possible contraindications (Who should not receive online treatment for social anxiety?).
Higher number of treatment completers.Ignore problems of comorbidity/co-occurring disorders (such as depression, addictions etc.).

* Face-to-face therapy can endorse repetition of the learned material as well and many therapists are available for emergency calls/sessions.

** Good interventions allow for restricted social interactions in the beginning and endorse social exposure at a later moment.

Treatment Modalities of Online Therapy for Social Anxiety Disorder

So, how exactly does online treatment for social anxiety look like? There are different approaches, from full 1-on-1 sessions through video or phone calls, over semi-accompanied programs with brief weekly therapist-contact, to fully automated courses that are completed without any contact to a therapist whatsoever.

There are different delivery formats for social anxiety treatment via the internet. Like this, people who prefer to avoid direct contact with a therapist have the chance to enter therapy.

Which of these options is best for a given person depends on her particular situation and characteristics. Just as with the different types of social anxiety treatment discussed above, there is no one-size-fits-all approach when it comes to delivery format. All of these versions of treatment delivery have been scientifically studied and led to positive results.

For example, studies comparing the effects of in-person treatment for social anxiety and therapy which included therapist contact through the internet, concluded that their efficacy is equivalent (Andrews, Davies, & Titov, 2011; Hedman et al., 2011).

Other studies examined the effectiveness of self-help programs with and without guidance by a therapist, and were able to draw the same conclusion concerning their effectiveness (Berger et al., 2011; Botella et al., 2010; Furmark et al., 2009).

However, the therapeutic alliance emerging in treatment between patient and therapist is considered a crucial pillar in all psychotherapies (Ackermann et al., 2001). So, why do people benefit from these ways of treatment delivery as much as from psychotherapy delivered in person?

Studies have shown that people rate the therapeutic alliance established with their therapist online as positive as when done in person.

One reason stems from the fact that a therapeutic alliance can be established through the internet. A recent study by Pihlaja and colleagues (2018) found that clients evaluated the alliance established with their therapist online as positive as when established in person.

Another reason relates to the characteristics of people with social anxiety. Given that exposing oneself to another person provokes intense anxiety in many affected people, they refrain from seeking professional help.

Online therapy represents a way to receive guidance with little or no contact to their therapist. Given that this is often the first therapeutic intervention for socially anxious people after many years of suffering, they appreciate the opportunity and adhere to the treatment itinerary, thoroughly read the materials and follow through with the exercises.

Medication for Social Anxiety Disorder

Research on the effects of certain pharmaceutics in people with social anxiety disorder has been ongoing ever since the condition was recognized by the APA in 1980.

While earlier trials focused on the anxiety-reducing effects of benzodiazepines, β-blockers and MAOIs, the attention of investigations has since then expanded to SSRIs, SNRIs and RIMAs and other, more novel, substances.

Here, we will have a closer look on the most commonly prescribed medications for social anxiety disorder.

Social Anxiety Treatment 1 medication types for social anxiety disorder.jpeg

Whether or not a person with social anxiety disorder should receive medication should always be decided by a qualified professional and based on a thorough assessment of each individual case.

The evaluation must include screening for any co-occurring psychiatric and medical conditions (Schneier, Bragdon, Blanco, & Liebowitz, 2014). It is crucial to detect any relevant contraindications in order to avoid adverse treatment effects.

SSRIs & SNRIs for Social Anxiety Disorder

Selective serotonin reuptake inhibitors (SSRIs) were originally developed to treat depression. They limit the reuptake of the neurotransmitter serotonin after it has been released into the synaptic cleft, a common process in the central nervous system.

Serotonin norepinephrine reuptake inhibitors (SNRIs) work in a similar fashion, but additionally to serotonin they inhibit the reabsorption of norepinephrine after its release into the synaptic cleft. Just as SSRIs, SNRIs belong to the group of second-generation antidepressant medication.

Social Anxiety Treatment 2 ssri and snri medication for social anxiety disorder.jpeg

In the mid-ninety’s, the first trials examining the effects of SSRIs and SNRIs in people with SAD were conducted. Since then, their efficacy for social anxiety disorder has been continuously proven in numerous randomized controlled trials (RCTs) and side-effects are usually tolerable for most individuals (Schneier, Bragdon, Blanco, & Liebowitz, 2014).

Due to their antidepressive properties, they usually have positive effects on depression as well, which often comes along with SAD. Therefore, SSRIs and SNRIs are considered first-choice medications for social anxiety disorder.

The most commonly prescribed SSRI and SNRI medications for social anxiety disorder are (Schneier, Bragdon, Blanco, & Liebowitz, 2014):

  • Paroxetine
  • Fluvoxamine
  • Sertraline
  • Escitalopram and citalopram
  • Fluoxetine
  • Venlafaxine

All of the above medications have been shown to reduce social anxiety, with fluoxetine being the only substance that showed mixed results (Schneier, Bragdon, Blanco, & Liebowitz, 2014).

As it is common for antidepressants that their effects usually manifest after about four weeks of treatment, its anxiety-reducing effects can and should be expected around the same time.

MAOIs & RIMAs for Social Anxiety Disorder

Monoamine Oxidase Inhibitors (MAOIs) constrain the enzyme monoamine oxidase, whose job is to break down serotonin, dopamine and norepinephrine.

Since MAOIs block this enzyme, the neurotransmitters are not broken down anymore, which increases their concentration in the brain. This effect is not only of benefit for people with depression, but also for those suffering from social anxiety disorder.

Phenelzine and tranylcypromine, the most common MAOIs, have been proven effective in social anxiety treatment (Blanco et al., 2010; Gelernter et al., 1991; Heimberg et al., 1998; Liebowitz et al., 1992, Nardi et al., 2010; Versiani et al., 1992).

MAOIs tend to produce more side-effects than the previously discussed medications and can lead to hypertensive crisis when too much norepinephrine is released, which can be the result of consuming certain foods.

Reversible Inhibitors of Monoamine Oxidase A (RIMAs) also bind and inhibit monoamine oxidase A. However, opposed to MAOIs, they do so reversibly.

This means that some of the neurotransmitters previously mentioned are broken down after their release into the synaptic cleft. This is especially important in the case of norepinephrine, since this drastically decreases the chances of hypertensive crisis.

Be that as it may, their reversibility comes along with lower efficacy in the treatment of social anxiety disorder (Schneier, Bragdon, Blanco, & Liebowitz, 2014). The only marketed RIMA is moclobemide. Brofaromine, another one, has led to good results in three RCTs, but has not been marketed.

Benzodiazepines for Social Anxiety Disorder

Benzodiazepines, often referred to as “benzos”, form part of the drug family of minor tranquilizers and are among the most commonly prescribed medications for anxiety.

There are several of studies that support their efficacy in reducing social anxiety symptoms (Davidson et al., 1993; Munjack, Baltazar, Bohn, Cabe, & Appleton, 1990; Ontiveros, 2008; Versiani, Amrein, & Montgomery, 1997).

Clonazepam and bromazepam, but not aplrazolam (Gelernter et al., 1991), can be considered effective medication for social anxiety based on the double-blind studies conducted.

Social Anxiety Treatment 3 benzodiazepines medication for social anxiety disorder.jpeg 1

Side-effects can be severe, including impaired cognition, high risk of falling, withdrawal effects, and especially abuse and dependency (Schneier, Bragdon, Blanco, & Liebowitz, 2014).

For this reason, the use of benzodiazepines for social anxiety should not be long-term and is rather used on an as-needed basis for public speaking and performance anxiety.

Also, as with all medications, close administration by a qualified professional is crucial to avoid adverse treatment effects.

β-Blockers for Social Anxiety Disorder

β-adrenergic antagonists, also called beta-blockers, block certain receptor sites in the nervous system which usually interact with the hormones and neurotransmitters epinephrine and norepinephrine.

When epinephrine binds to a receptor site, it stimulates a stress response. Beta-blockers inhibit this process by blocking the receptor sites and therefore reduce the body’s stress response.

Social Anxiety Treatment 4 how do beta blockers work infographic.jpeg

When taken before a feared performance situation, such as public speaking, β-blockers are effective in decreasing the anxiety response of the automatic nervous system (Hartley, Ungapen, Davie, & Spencer, 1983; Neftel et al., 1982).

However, when taken on a daily basis by people with generalized SAD (anxiety in most social situations), this type of medication does not bring any benefit (Liebowitz et al., 1992, Turner, Beidel, & Jacob, 1994).

Therefore, the use of beta-blockers in the treatment of social anxiety disorder seems restricted to those individuals who suffer from performance or public speaking anxiety on an as-needed basis (Schneier, Bragdon, Blanco, & Liebowitz, 2014).

CBD for Social Anxiety Disorder

Cannabidiol, a cannabinoid also known as CBD, has been subject to many scientific investigations throughout the last decade and represents a novel, promising medication for social anxiety.

It has been reported that CBD has an impact on the activation of certain brain areas, specifically in lymbic and paralymbic regions (Crippa et al., 2011). These changes in activation relate to reductions in anxiety in people with SAD.

Social Anxiety Treatment 5 cbd cannabidiol brain activity lowers
CBD intake is associated with lower subjective anxiety in people with SAD, probably due to changes of activity in lymbic and paralymbic brain areas.

Since CBD is a nonaddictive component of the Cannabis sativa plant and has  nonpsychotomimetic properties, it may become more commonplace as a treatment for social anxiety in the near future.

Several trials have shown promising results, confirming the anxiety-reducing effects of CBD in people with SAD and avoidant personality disorder (e.g., Bergamaschi, Querioz, Chagas, Oliverira, & Martinis, 2011; Crippa et al., 2011; Masataka, 2019).

Practical Tips for Social Anxiety Disorder

While the literature discussed above refers to the official treatments of social anxiety and requires reaching out for professional help, there are also various practical and easy to implement interventions anybody can make use of in order to reduce and manage social anxiety symptoms by themselves.

In this section, we will discuss numerous tips for social anxiety that usually provide some relief for most affected people.

Sleep & Social Anxiety

As of today, there is a large body of evidence indicating that sleep deprivation not only takes a toll on our physical, but also our mental health.

Sleep loss has been consistently associated with emotional irritability, aggression and anxiety (e.g., Anderson & Platten, 2011; Horne, 1985; Dinges et al., 1997; Zohar, Tzischinsky, Epstein, & Lavie, 2005; Minkel, et al., 2012). In other words, our emotional reactivity is significantly impacted by the duration and quality of sleep we get.

For people with SAD, this means that getting enough shut eye and prioritizing good sleep should form part of the basics.

If you suffer from sleep disruptions, it is important to follow some basic rules in order to get good, sufficient rest. Among the most important rules of thumb experts recommend are the following:

  • no caffeine after lunchtime
  • don’t use alcohol to fall asleep
  • regular physical activity
  • create a personal ritual before going to bed (like reading, meditating, use certain scents, etc.)
  • only go to bed when tired
  • don’t watch TV or read in your bed (you want your brain to associate this place with sleep, not with being awake)
  • get up around the same time everyday
  • no naps during daytime if you have trouble sleeping at night

Keep in mind that sleep cannot be forced. Instead of attempting to sleep, simply try to relax. Your mind and body recover when you lay down, shut your eyes, breathe slowly and keep calm.

Physical Exercise & Social Anxiety

Like sleep, physical exercise has an important impact on health. This is true for our physical, but also for our mental well-being.

Research regarding the mental health benefits of regular physical activity has been piling up over the last decades. There have even been some trials that specifically included people with SAD in order to see if exercise is an effective supplementary intervention for this population.

Adding physical exercise to standard CBT for social anxiety improves treatment efficacy.

For example, one study investigated whether adding physical activity to a traditional group CBT treatment for social anxiety would be more effective compared to the CBT intervention by itself (Merom et al., 2008).

While patients with generalized anxiety disorder and panic disorder did not benefit from the exercise induction, those with SAD averaged significant improvements on measures for anxiety, depression, and stress. The study participants were instructed to engage in simple walking on five days a week for a total of 150 minutes. The intervention lasted 10 weeks.

The positive effects of physical exercise on social anxiety could be replicated by other research teams, suggesting that it is an effective intervention (Jazaieri, Goldin, Werner, Ziv, & Gross, 2012; Jazaieri, Lee, Goldin, & Gross, 2016; LeBouthillier and Asmundson, 2017). This was found to be true for aerobic exercise, such as running or swimming, and for anaerobic activities, such as resistance training.

Physical exercise has been shown to have anxiety-reducing effects due to improvements on a hormonal, cognitive, and psychological level.

As exercise provides a wide range of health benefits, not only related to anxiety, becoming more physically active represents a desirable lifestyle change for most people with SAD.

A recent systematic review and meta-analysis of numerous studies examining the effects of exercise on anxiety concluded that high intensity exercise regimens are more effective in reducing anxiety symptoms than low intensity training (Aylett, Small, & Bower 2018).

Additionally, the anxiety-reducing effects of exercise could be maintained several month after completing the intervention. Make sure to always consult with your physician before starting a new workout routine.

Breathing Techniques for Social Anxiety

Breathing not only is crucial to our immediate survival, but the way we engage in it has an important impact on physiological, and therefore psychological, processes in our body.

When carried out in a particular way, breathing has been shown to increase parasympathetic activity, which slows down the heart rate (Zaccaro et al., 2018).

Social Anxiety Treatment 6 deep breathing activates the parasympathetic nervous system.jpeg

Additionally, slow breathing exercises have the potential to alter brain activity in a way which promotes emotional control and have been linked to greater well-being.

When faced with a stressful event, such as a feared social situation, the brain triggers the release of cortisol. Cortisol is a stress hormone which helps the body handle difficult situations.

In the case of social anxiety, cortisol is released in social situations which pose no real threat, and therefore has a counterproductive effect. Slow breathing practice has been suggested to normalize the body’s stress response (Lehrer et al., 2010) and deep breathing is associated with sustained attention, positive emotion, and lower cortisol levels (Ma et al., 2017).

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Different types of breathing techniques have proven beneficial to psychological well-being, due to emotion enhancement and reduction of anxiety, depression and stress (Brown and Gerbarg, 2005a,b; Anju et al., 2015; Stromberg, Russel, & Carlson, 2015).

Diaphragmatic breathing, also known as “deep breathing“, is a broad term which encapsulates various types of breathing techniques with origins in yoga, meditation, and psychotherapy. Treatment for social anxiety often includes some of them.

Deep breathing may be practiced regularly or on an as-needed basis before, during, and after a feared social situation by people with SAD.

However, for inexperienced newcomers, it is important to follow some basic guidelines to avoid adverse effects. It is not recommended to engage in rapid, consecutive inhalations, as this increases the risk of hyperventilation and activates the sympathetic nervous system, which rather amplifies anxiety.

Deep breathing has been shown to reduce anxiety symptoms.

While breath holding for short periods of time is often recommended and can help reduce anxiety, it may also lead to negative effects if the air is retained for too long (Krishnananda, 2009). Exercises which include long breath holding should therefore be practiced with a qualified health care professional.

There are many different deep breathing exercises that can help reduce anxiety in social situations. One of them is the so-called box-breathing technique, which is especially helpful to help people manage stressful situations (Norelli, Long, & Krepps, 2020).

This exercise does not instruct to breath into a box (as one may suspect), but to imagine a box with 4 equal parts, with each of them representing one of its steps. It can be practiced before, during, or after a feared social situation and does not require a tranquil, stress free environment in order to work.

The box breathing technique can be used to manage social anxiety before, during or after a scary social event.
  1. Inhale through the nose (4 seconds)
  2. Hold breath (4 seconds)
  3. Exhale through mouth or nose (4 seconds)
  4. Hold breath (4 seconds)

This process is then repeated as needed and as it feels comfortable. The length of the individual steps can be adjusted to the needs and possibilities of each individual. For example, if you feel more comfortable with a count of two in each step, simply adjust the exercise.

Exposure for Social Anxiety

People with social anxiety usually display a strong tendency to avoid the situations they fear. If they face these social scenarios despite their anxiety, they often engage in so-called safety behaviors in order to avoid the feared outcomes, such as being laughed at, humiliated, or rejected.

For instance, a typical safety behavior of people who are afraid of seeming socially inept or reserved is taking out the phone in the presence of others. The intention behind this is to not seem like someone without friends or like a person who is incapable of engaging in conversation.

Both of the above scenarios, avoiding the situation completely as well as facing the situation engaging in safety behaviors, can be seen as avoidance of the feared situation.

By pretending to be chatting with others by phone, the individual does not expose herself to the situation she really fears. In this case, this could be being in a small group of people who are having a conversation and feeling the pressure to engage in it.

Exposure to the feared situations is very effective in reducing social anxiety symptoms (Turner, Beidel, & Jacob, 1994; Alström, Nordlund, Persson, Hårding, & Ljungqvist, 1984).

In fact, it can be seen as probably the most powerful tool when it comes to treatment for social anxiety disorder and usually forms part of any successful intervention in one way or another.

Any list with tips for people with social anxiety would not be complete if it did not include encouragement to seek exposure to feared social scenarios.

Seeking exposure to feared situations is probably the most powerful tool to overcome social anxiety disorder.

While exposure exercises may be discussed with a therapist in official social anxiety treatment, looking for opportunities in everyday life to face situations you have been avoiding due to fear of disapproval is certainly a huge step into the right direction.

Most certainly, this process can be gradual as it can be quite challenging. However, if you are persistent in this pursuit, you are on the right track.

Wrapping up: If you start improving your sleep habits, to work out sufficiently, start using your breathing to your advantage and begin facing your fears step by step, you are off to a good start to overcome social anxiety.

If you are interested in more practical tips for SAD, check out our actionable intel for social anxiety disorder.

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